Diuretic Therapy Research Articles

Carbohydrate antigen 125-guided pre-TAVI medical optimization: impact on quality of life and clinical outcomes

Introduction and objectivesCarbohydrate antigen 125 (CA125), a biomarker associated with fluid overload, has proven useful in managing diuretic therapy in heart failure. We aimed to evaluate the impact of diuretic optimization guided by CA125 before transcatheter aortic valve implantation (TAVI) on outcomes. MethodsThis prospective interventional study enrolled patients scheduled for TAVI, in whom baseline CA125 was measured 2 weeks before TAVI. Patients with CA125 ≥ 20 U/mL underwent diuretic up-titration before TAVI. Three groups were included: group I) baseline CA125 <20 U/mL; IIa) CA125 ≥ 20 U/mL that decreased after treatment, and IIb) CA125 ≥ 20 U/mL that did not decrease. The primary outcome was changes in the Kansas City Cardiomyopathy Questionnaire at 3 and 12 months. The secondary endpoint was clinical events. ResultsThe study included 184 patients (115 group I, 46 IIa, and 23 IIb). Groups I and IIa exhibited early and sustained improvements in the Kansas City Cardiomyopathy Questionnaire (group I: 18.9 points [95%CI, 15.7-22.1; P <.001] at 90 days, and 18.1 [95%CI, 14.9-21.4, P <.001] at 1 year; group IIa: 21.1 points [95%CI, 15.4-26.7; P <.001] and 19.5 [95%CI, 13.9-25.1; P <.001] respectively). In contrast, in group IIb there was no significant improvement at 90 days (P=.12), with improvement being significant only at 1 year (17.8 points, 95%CI, 5.9-29.6; P=.003). Over a median follow-up of 20.7 months, there were 63 (27.83%) deaths or heart failure admissions. Multivariate analysis showed a lower risk of events in group I vs IIb (HR, 0.28; 95%CI, 0.14-0.58; P <.001), and IIa vs IIb (HR, 0.24; 95%CI, 0.11-0.55; P <.001). ConclusionsPatients with persistently high CA125 despite diuretic therapy pre-TAVI showed slower functional recovery and poorer clinical outcomes after TAVI.

Pre-emptive treatment of heart failure exacerbations in patients managed with the HeartLogic™ algorithm.

Heart failure (HF) is a chronic disease affecting 64 million people worldwide and places a severe burden on society because of its mortality, numerous re-hospitalizations and associated costs. HeartLogic™ is an algorithm programmed into implanted devices incorporating several biometric parameters which aims to predict HF episodes. It provides an index which can be monitored remotely, allowing pre-emptive treatment of congestion to prevent acute decompensation. We aim to assess the impact and security of pre-emptive HF management, guided by the HeartLogic™ index. The HeartLogic™ France Cohort Study is an investigator-initiated, prospective, multi-centre, non-randomized study. Three hundred ten patients with a history of HF (left ventricular ejection fraction ≤40%; or at least one episode of clinical HF with elevated NT-proBNP ≥450ng/L) and implanted with a cardioverter defibrillator enabling HeartLogic™ index calculation will be included across 10 French centres. The HeartLogic™ index will be monitored remotely for 12months and in the event of a HeartLogic™ index ≥16, the local investigator will contact the patient for assessment and adjust HF treatment as necessary. The primary endpoint is unscheduled hospitalization for HF. Secondary endpoints are all-cause mortality, cardiovascular death, HF-related death, unscheduled hospitalizations for ventricular or atrial arrhythmia and HeartLogic™ index evolution over time. Blood samples will be collected for biobanking, and quality of life will be assessed. Finally, the safety of a HeartLogic™-triggered strategy for initiating or increasing diuretic therapy will be assessed. A blind and independent committee will adjudicate the events. The HeartLogic™ France Cohort Study will provide robust real-world data in a cohort of HF patients managed with the HeartLogic™ algorithm allowing pre-emptive treatment of heart failure exacerbations.

Advances in the treatment of malignant ascites in China.

Malignant ascites (MA) often occurs in recurrent abdominal malignant tumors, and the large amount of ascites associated with cancerous peritonitis not only leads to severe abdominal distension and breathing difficulties, but also reduces the patient's quality of life and ability to resist diseases, which usually makes it difficult to carry out anti-cancer treatment. The exploration of MA treatment methods is also a key link in MA treatment. This article is going to review the treatment of MA, to provide details for further research on the treatment of MA, and to provide some guidance for the clinical treatment of MA. This review analyzes various expert papers and summarizes them to obtain the paper. There are various treatment methods for MA, including systemic therapy and local therapy. Among them, systemic therapy includes diuretic therapy, chemotherapy, immunotherapy, targeted therapy, anti angiogenic therapy, CAR-T, and vaccine. Local therapy includes puncture surgery, peritoneal vein shunt surgery, acellular ascites infusion therapy, radioactive nuclide intraperitoneal injection therapy, tunnel catheter, and intraperitoneal hyperthermia chemotherapy. And traditional Chinese medicine treatment has also played a role in enhancing efficacy and reducing toxicity to a certain extent. Although there has been significant progress in the treatment of MA, it is still one of the clinical difficulties. Exploring the combination or method of drugs with the best therapeutic effect and the least adverse reactions to control MA is still an urgent problem to be solved.

Diuretic Strategies in Acute Decompensated Heart Failure: A Narrative Review.

Heart failure is a common condition with considerable associated costs, morbidity, and mortality. Patients often present to hospital with dyspnea and edema. Inadequate inpatient decongestion is an important contributor to high readmission rates. There is little evidence concerning diuresis to guide clinicians in caring for patients with acute decompensated heart failure. Contemporary diuretic strategies have been defined by expert opinion and older landmark clinical trials. To present a narrative review of contemporary recommendations, along with their underlying evidence and pharmacologic rationale, for diuretic strategies in inpatients with acute decompensated heart failure. PubMed, OVID, and Embase databases were searched from inception to December 22, 2022, with the following search terms: heart failure, acute heart failure, decompensated heart failure, furosemide, bumetanide, ethacrynic acid, hydrochlorothiazide, indapamide, metolazone, chlorthalidone, spironolactone, eplerenone, and acetazolamide. Randomized controlled trials and systematic reviews involving at least 100 adult patients (> 18 years) were included. Trials involving torsemide, chlorothiazide, and tolvaptan were excluded. Early, aggressive administration of a loop diuretic has been associated with expedited symptom resolution, shorter length of stay, and possibly reduced mortality. Guidelines make recommendations about dose and frequency but do not recommend any particular loop diuretic over another; however, furosemide is most commonly used. Guidelines recommend that the initial furosemide dose (on admission) be 2-2.5 times the patient's home dose. A satisfactory diuretic response can be defined as spot urine sodium content greater than 50-70 mmol/L at 2 hours; urine output greater than 100-150 mL/h in the first 6 hours or 3-5 L in 24 hours; or a change in weight of 0.5-1.5 kg in 24 hours. If congestion persists after the maximization of loop diuretic therapy over the first 24-48 hours, an adjunctive diuretic such as thiazide or acetazolamide should be added. If decongestion targets are not met, continuous infusion of furosemide may be considered. Heart failure with congestion can be managed with careful administration of high-dose loop diuretics, supported by thiazides and acetazolamide when necessary. Clinical trials are underway to further evaluate this strategy.

Skin dehydration monitoring with optical spectroscopy allows assessment of water content in the organism: Thermal and physical loads, diuretic therapy.

This study investigates the relationship between body hydration levels and skin hydration using spatially resolved diffuse reflectance spectroscopy. The research involved monitoring skin dehydration and rehydration under various conditions, including thermal and physical loads on healthy volunteers, and diuretic therapy in patients with edema syndrome. Findings indicate a correlation between body mass reduction and skin hydration: a 1% loss in body mass corresponds to a 10% decrease in skin hydration. During thermal stress, water absorption at 970 nm decreased monotonically without recovery. Physical activity resulted in approximately 10% changes in skin water content within 20 min, followed by rehydration. Patients with edema syndrome exhibited the most substantial decrease in water absorption amplitude, at nearly 30%, during diuretic treatment. These results support optical spectroscopy as a non-invasive tool for assessing body hydration, with implications for developing portable hydration monitoring devices for clinical and sports applications.

Decongestion in Acute Heart Failure-Time to Rethink and Standardize Current Clinical Practice?

Most episodes of acute heart failure (AHF) are characterized by increasing signs and symptoms of congestion, manifested by edema, pleura effusion and/or ascites. Immediately and repeatedly administered intravenous (IV) loop diuretics currently represent the mainstay of initial therapy aiming to achieve adequate diuresis/natriuresis and euvolemia. Despite these efforts, a significant proportion of patients have residual congestion at discharge, which is associated with a poor prognosis. Therefore, a standardized approach is needed. The door to diuretic time should not exceed 60 min. As a general rule, the starting IV dose is 20-40 mg furosemide equivalents in loop diuretic naïve patients or double the preexisting oral home dose to be administered via IV. Monitoring responses within the following first hours are key issues. (1) After 2 h, spot urinary sodium should be ≥50-70 mmol/L. (2) After 6 h, the urine output should be ≥100-150 mL/hour. If these target measures are not reached, the guidelines currently recommend a doubling of the original dose to a maximum of 400-600 mg furosemide per day and in patients with severely impaired kidney function up to 1000 mg per day. Continuous infusion of loop diuretics offers no benefit over intermittent boluses (DOSE trial). Emerging evidence by recent randomized trials (ADVOR, CLOROTIC) supports the concept of an early combination diuretic therapy, by adding either acetazolamide (500 mg IV once daily) or hydrochlorothiazide. Acetazolamide is particularly useful in the presence of a baseline bicarbonate level of ≥27 mmol/L and remains effective in the presence of preexisting/worsening renal dysfunction but should be used only in the first three days to prevent severe metabolic disturbances. Patients should not leave the hospital when they are still congested and/or before optimized long-term guideline-directed medical therapy has been initiated. Special attention should be paid to AHF patients during the vulnerable post-discharge period, with an early follow-up visit focusing on up-titrate treatments of recommended doses within 2 weeks (STRONG-HF).

Unlocking the Potential of Acetazolamide: A Literature Review of an Adjunctive Approach in Heart Failure Management.

Background: Heart failure (HF) patients often experience persistent fluid overload despite standard diuretic therapy. The adjunctive use of acetazolamide, a carbonic anhydrase inhibitor, in combination with loop diuretics has shown promise in improving decongestion and diuretic efficacy. This literature review aims to analyze six studies evaluating the effectiveness of acetazolamide as an additive treatment for acute decompensated heart failure (ADHF) and its impact on various outcomes. Methods: We searched the PubMed database using the terms "acetazolamide heart failure". We refined our search with specific filters (as shown our PRISMA flow diagram) and exclusion criteria, narrowing down our results to five studies. We included an extra study via expert recommendation, ultimately including six studies for comprehensive analysis. Results: The review highlights the positive effects of acetazolamide on decongestion, natriuresis, and diuresis in HF patients. However, it also showcases the limitations of these trials. Discussion: While the reviewed studies demonstrate the potential benefits of acetazolamide in enhancing decongestion and diuretic efficiency, there are limitations to consider, including small sample sizes, lack of blinding, and limited external validity. Further research is needed to confirm these findings, compare acetazolamide with other diuretic combinations, and explore its effects in a broader population of heart failure patients, including those in the United States. The use of acetazolamide in HF management warrants continued investigation to optimize its role in improving decongestion and patient outcomes.

Serum electrolytes in children with heart failure on diuretic therapy at Jakaya Kikwete Cardiac Institute, Dar es salaam, Tanzania: a cross-sectional study

Serum electrolytes in children with heart failure on diuretic therapy at Jakaya Kikwete Cardiac Institute, Dar es salaam, Tanzania: a cross-sectional study

Assessment of Sodium Disturbances in Chronic Liver Disease Suffering from Diarrhea with Dehydration

Background Chronic liver disease (CLD) significantly impacts global health, affecting nearly 1.5 billion individuals. Sodium disturbances are common in CLD and can lead to severe systemic effects. However, the relationship between these disturbances and CLD-related complications such as diarrhea and dehydration is complex and not fully understood. Objective: To assess the sodium disturbances in chronic liver disease patients suffering from diarrhea with dehydration presenting at a tertiary care hospital, in Karachi, Pakistan. Methodology: A cross-sectional study was conducted from October 2022 to July 2023, including individuals aged &gt;18 years diagnosed with CLD, experiencing diarrhea and dehydration, and on diuretic therapy. The blood sample was collected from all of the participants and sent to a laboratory for analysis. The blood is then tested to measure the concentration of sodium in milliequivalents per liter (meq/L). The normal range for sodium levels in the blood typically falls between 135 to 145 meq/L. Levels below or above this range can indicate sodium imbalances. Descriptive statistics and inferential statistics were performed on SPSS. Results: The mean age of the participants was 33.35 years, with a standard deviation of 8.01. Of 126 patients, 38.1% were male, 27% had hypertension, and 15.1% had diabetes. The mean sodium concentration was found as 132.17±14.23 meq/L, with 42.9% of CLD patients experiencing diarrhea and dehydration having sodium levels &lt;135 meq/L. Diabetic CLD patients showed a significant association with low sodium levels (73.7% with sodium &lt;135 meq/L). Conclusion: A high prevalence of sodium imbalances among CLD patients suffering from diarrhea and dehydration, with diabetes being a significant contributing factor.

A Case of Aortopulmonary Fistula with Post-Operative Aortic Pseudoaneurysm Diagnosed by Transesophageal Echocardiography.

Tracheobronchial or esophageal fistula after aortic surgery has been reported sporadically in the literature, however, reports of an aortopulmonary fistula associated with a post-operative aortic pseudoaneurysm are rare. We experienced a case of refractory heart failure due to an aortopulmonary fistula associated with a post-operative aortic pseudoaneurysm. A 60-year-old man who had undergone aortic surgery 2 years earlier was hospitalized for congestive heart failure. He was diagnosed with refractory heart failure after 10 days of diuretic therapy failed to improve his condition. He underwent a contrast-enhanced computed tomography (CT) scan and was suspected to have pulmonary artery perforation of an aortic pseudoaneurysm at the anastomotic site of the ascending aortic surgery. Transesophageal echocardiography showed shunt blood flow from the aortic aneurysm into the right pulmonary artery, leading to a definitive diagnosis of aortopulmonary fistula with post-operative aortic pseudoaneurysm. Computed tomography angiography is commonly used to diagnose an aortic fistula; however, diagnosis is often difficult because of the subtle imaging findings. We highlight the usefulness of transesophageal echocardiography in providing a definitive diagnosis and detailed morphologic information on this pathophysiology.

Diuretic resistance and the role of albumin in congestive heart failure.

Diuresis with loop diuretics is the mainstay treatment for volume optimization in patients with congestive heart failure, in which perfusion and volume expansion play a crucial role. There are robust guidelines with extensive evidence for the management of heart failure; however, clear guidance is needed for patients who do not respond to standard diuretic treatment. Diuretic resistance (DR) can be defined as an insufficient quantity of natriuresis with proper diuretic therapy. A combination of diuretic regimens is used to overcome DR and, more recently, SGLT2 inhibitors have been shown to improve diuresis. Despite DR being relatively common, it is challenging to treat and there remains a notable lack of substantial data guiding its management. Moreover, DR has been linked with poor prognosis. This review aims to expose the multiple approaches for treatment of patients with DR and the importance of intravascular volume expansion in the response to therapy.

The evolution of ideas about the diagnosis and treatment of various phenotypes of chronic heart failure in type 2 diabetes mellitus

Despite the successes achieved in diagnosis and treatment, HF, regardless of the phenotype, remains one of the significant problems in the health sector, due to the high incidence, frequency of hospitalization, disability and mortality. In turn, patients with both type 2 diabetes and prediabetes are a vulnerable group in terms of the development of CHF. CH-sFV therapy has been focused for several decades on the treatment of concomitant diseases such as type 2 diabetes, hypertension, coronary heart disease, obesity and, if necessary, initiation of diuretic therapy to improve the quality of life. However, to date, great progress has been made in the treatment of HF-sFV. All guidelines for the management of patients with HF, based on the results of large randomized trials, postulate that iNGLT2 types are the basic drugs for the treatment of patients with HF, regardless of PV. Algorithms of specialized medical care for patients with diabetes recommend the appointment of iNGLT type 2 in the presence or high risk of developing CHF and/or CKD, regardless of the HbA1c level, in patients with type 2 diabetes to reduce the risk of hospitalization for HF, cardiovascular events and reduce the risks of CKD progression.

A Phenomapping Tool and Clinical Score to Identify Low Diuretic Efficiency in Acute Decompensated Heart Failure

BackgroundIndividuals with acute decompensated heart failure (ADHF) have a varying response to diuretic therapy. Strategies for the early identification of low diuretic efficiency to inform decongestion therapies are lacking. ObjectivesThe authors sought to develop and externally validate a machine learning–based phenomapping approach and integer-based diuresis score to identify patients with low diuretic efficiency. MethodsParticipants with ADHF from ROSE-AHF, CARRESS-HF, and ATHENA-HF were pooled in the derivation cohort (n = 794). Multivariable finite-mixture model-based phenomapping was performed to identify phenogroups based on diuretic efficiency (urine output over the first 72 hours per total intravenous furosemide equivalent loop diuretic dose). Phenogroups were externally validated in other pooled ADHF trials (DOSE/ESCAPE). An integer-based diuresis score (BAN-ADHF score: blood urea nitrogen, creatinine, natriuretic peptide levels, atrial fibrillation, diastolic blood pressure, hypertension and home diuretic, and heart failure hospitalization) was developed and validated based on predictors of the diuretic efficiency phenogroups to estimate the probability of low diuretic efficiency using the pooled ADHF trials described earlier. The associations of the BAN-ADHF score with markers and symptoms of congestion, length of stay, in-hospital mortality, and global well-being were assessed using adjusted regression models. ResultsClustering identified 3 phenogroups based on diuretic efficiency: phenogroup 1 (n = 370; 47%) had lower diuretic efficiency (median: 13.1 mL/mg; Q1-Q3: 7.7-19.4 mL/mg) than phenogroups 2 (n = 290; 37%) and 3 (n = 134; 17%) (median: 17.8 mL/mg; Q1-Q3: 10.8-26.1 mL/mg and median: 35.3 mL/mg; Q1-Q3: 17.5-49.0 mL/mg, respectively) (P < 0.001). The median urine output difference in response to 80 mg intravenous twice-daily furosemide between the lowest and highest diuretic efficiency group (phenogroup 1 vs 3) was 3,520 mL/d. The BAN-ADHF score demonstrated good model performance for predicting the lowest diuretic efficiency phenogroup membership (C-index: 0.92 in DOSE/ESCAPE validation cohort) that was superior to measures of kidney function (creatinine or blood urea nitrogen), natriuretic peptide levels, or home diuretic dose (DeLong P < 0.001 for all). Net urine output in response to 80 mg intravenous twice-daily furosemide among patients with a low vs high (5 vs 20) BAN-ADHF score was 2,650 vs 660 mL per 24 hours, respectively. Participants with higher BAN-ADHF scores had significantly lower global well-being, higher natriuretic peptide levels on discharge, a longer in-hospital stay, and a higher risk of in-hospital mortality in both derivation and validation cohorts. ConclusionsThe authors developed and validated a phenomapping strategy and diuresis score for individuals with ADHF and differential response to diuretic therapy, which was associated with length of stay and mortality.

Effect of Acetazolamide Additional Therapy on Loop Diuretic for Achieving an Effective Treatment in Acute Heart Failure Patients: A Systematic Review

Abstract: Hospital readmissions are primarily caused by signs and symptoms of congestion of acute heart failure (AHF). Loop diuretics are commonly used to treat volume excess. It has been suggested by earlier studies in AHF patients that combination of loop diuretics with acetazolamide can increase the effectiveness of loop diuretics. This study aimed to obtain the impact of acetazolamide addition on loop diuretic therapy in AHF patients and assess the benefit of the combination. This was a systematic review using PubMed and ScienceDirect to retrieve data in 2013 and 2023, focusing on Randomized Controlled Trials (RCTs) involving AHF patients treated with both loop diuretics and acetazolamide. The results showed that 573 patients from a total of four RCTs were included in the study. Acetazolamide additional therapy helped loop diuretic to increase natriuresis (in all of the studies) and urine output (in two studies). The congestion symptoms also reduced in patients who received acetazolamide additional therapy on dose 500 mg intravenously within three days (p&lt;0.05) in two studies. However, patients who received acetazolamide therapy also had an increase in serum creatinine levels in two studies. In conclusion, adding acetazolamide to loop diuretic therapy can increase the effectiveness of loop diuretics to achieve successful decongestion in AHF patients. Additionally, acetazolamide-treated individuals exhibit natriuresis and urin output higher than those in the control group, despite it also raises serum creatinin level. Keywords: acetazolamide; loop diuretics; acute heart failure; decongestion

Timing for combined diuretic therapy in acute heart failure: should we continue waiting for the poor response?

Decongestion is an important primary goal in acute heart failure treatment. Loop diuretics remain a fundamental role in congestion management and symptom improvement in patients with acute heart failure. Diuretic combination contributes to achieving better diuretic efficacy. However, the optimal timing for diuretic combination in clinical practice has not been distinctly recommended in current guidelines.

How Much Furosemide Should be Administered to Prevent Transfusion-Associated Circulatory Overload? Results of a Dose-Finding Study

BACKGROUND: Transfusion-associated circulatory overload (TACO) is a common but under-reported complication of transfusion therapy, and results in significant morbidity and mortality. Pre-transfusion furosemide has been proposed as a mitigating strategy but has not received widespread endorsement, in part due to uncertainty regarding safe and effective dosing. An observational study was therefore conducted with the goal of creating a reliable dose-response curve in patients at high risk of TACO, using the statistical technique of Multiple Comparisons Procedure with Modelling (MCP-MOD). METHODS: Eligible patients were identified by screening bolus intravenous (IV) furosemide orders at two large academic hospitals. Eligibility criteria were selected to mimic those of a planned randomized controlled trial (RCT) of pre-transfusion furosemide for the prevention of TACO. Inclusion criteria were inpatients 50 years of age or older. Exclusion criteria were active bleeding, hemodynamic instability, glomerular filtration rate (GFR) &amp;lt; 30mL/min or need for dialysis, diuretic therapy (other than furosemide) administered less than 24 hours, furosemide (either IV or PO) administered less than 12 hours, or exogenous albumin administered less than 8 hours prior to index furosemide therapy. The primary outcome measure was the total volume of urine output in the six hours following IV furosemide administration. MCP-MOD analysis was performed after every 50 patients and continued until a weight-adjusted dose-response curve could be established with 100 mL precision, using the following covariates: age, sex, mean arterial pressure (MAP), serum albumin, GFR and history of chronic furosemide use. RESULTS: A total of 149 participants (53 female and 96 male) were enrolled over 2 years. As too few patients received doses exceeding 0.6 mg/kg to allow for a precise dose-response curve, only 132 patients receiving weight-adjusted doses ranging from 0.1 to 0.6 mg/kg were included in the MCP-MOD analysis. The characteristics of these patients are shown in Table 1. The dose-response curve formula that was derived from these patients was: Urine Output at 6 hours (mL) = 717.21 + 191.33 ln(dose (mg)/weight (kg)) + 0.73 × Age (years) + 103.37 × Sex (M=1/F=0) + 1.63 × GFR (ml/min) + 5.45 × MAP (mmHg) - 9.56 × albumin (g/L) - 62.31 × chronic diuretic use (Y=1/N-0) The curve with accompanying 95% confidence intervals is shown in Figure 1 This formula suggests that in an 80 kg patient with a GFR of 75 mL/min, a MAP of 85 mmHg, albumin of 40 g/L and no history of chronic diuretic use, 10 mg of IV furosemide should produce a diuresis of approximately 600 mL, sufficient to prevent circulatory overload from the transfusion of 1 unit of RBCs. A dose of 20 mg would be required to achieve a similar diuresis in patients with either a MAP &amp;lt; 60 mmHg, or a combination of both a GFR &amp;lt; 45 mL/min and a history of chronic diuretic use. CONCLUSIONS: A statistically precise dose-response curve for IV furosemide is possible with the inclusion of relevant clinical covariates, and can be used to guide dosing decisions in patients at risk of transfusion-associated circulatory overload. This formula derived from this study will inform the dosing recommendations of a planned RCT: Transfusion-Associated Circulatory Overload: Best Eliminated by Lasix® (TACO-BEL).

Comparative analysis of diuretic therapy and ultrafiltration in the efficacy of acute heart failure treatment

This article examines the role of furosemide and ultrafiltration in the treatment of acute heart failure. Furosemide, a loop diuretic, is successfully employed to reduce circulating blood volume and arterial pressure while increasing urea and uric acid excretion. The study compares two methods of furosemide administration: continuous infusion and intermittent injections, highlighting their advantages and limitations. Ultrafiltration, a method for removing excess fluid from the body, presents a promising alternative to diuretic therapy in the treatment of acute heart failure. This method allows for more precise fluid removal, preservation of kidney function, reduction of patient deterioration risks, improvement in their quality of life, and a decrease in diuretic dosages. Data analysis underscores the efficacy of ultrafiltration in managing acute heart failure with fluid overload and offers a perspective for future therapeutic practices.

Diuretics versus volume expansion for acute pulmonary embolism: a systematic review and meta-analysis

Abstract Background/Introduction The potential benefit of diuretics over volume expansion in patients with acute submassive pulmonary embolism with right ventricle dysfunction is controversial. Purpose This study aims to compare the effects of diuretic therapy versus volume expansion in patients hospitalized for pulmonary embolism with right ventricle dysfunction. Methods We performed a systematic review and meta-analysis of studies comparing diuretics and volume expansion for acute submassive pulmonary embolism. PubMed, Embase, and Cochrane databases were searched up to January 20, 2023. Data were extracted from published reports and quality assessment was performed per Cochrane recommendations. Review Manager 5.1 was used for statistical analysis. A random-effects model was used to calculate a pooled effect size and 95% confidence interval. Results Three studies and 176 patients were included. Follow-up ranged from 2 to 30 days. The mean age was 67.5 ± 17.5 years and 52.3% were female. There were no differences between groups regarding the 24h-variation of heart rate (MD -5.98, 95% CI -14.41 to 2.46 beats/min, P = 0.17; Fig. 1A) and systolic blood pressure (MD 9.68, 95% CI -2.94 to 22.30 mmHg, P = 0.13; Fig. 1B). Diuretic therapy was associated with a faster normalisation of BNP (MD -38.38, 95% CI -60.51 to -16.24 hours, P = 0.0007; Fig. 2A). In the 24h-echocardiography parameters, no difference was found in the tricuspid annular plane systolic excursion (TAPSE) (MD -0.15, 95% CI -2.04 to 1.74 mm, P = 0.87; Fig. 2B). Similarly, no significant difference in oxygen requirement, troponin normalization, and inotropic support was seen. Conclusions Compared with the volume expansion strategy, diuretic therapy was not associated with improved hemodynamic and echocardiography parameters at 24h. Prospective and more extensive randomised trials are warranted to confirm the efficacy and safety of diuretics in acute submissive pulmonary embolism with right ventricle dysfunction.

Predicting thrombus outcome during anticoagulation for left ventricular thrombus

Abstract Background Up to 22% of embolizations have been linked to left ventricular (LV) thrombosis. Oral anticoagulation (OAC) for at least 3 months is recommended for patients with LV thrombus, according to guidelines. The purpose of this study was to predict the resolution of thrombus in patients with LV thrombus who were taking OAC for 3 months. Methods We enrolled patients prospectively from 2020 to 2022 and retrospectively from 2013 to 2019 at a national center of cardiovascular diseases in China. Patients with a history of LV thrombus &amp;lt; 3 months were included. Eligible patients were administered OAC and scheduled for 3 months of follow-up visits. The primary efficacy outcome was the rate of thrombus resolution at 3 months. Safety outcomes and major cardiovascular adverse events were collected. The hazard ratio (HR) and 95% confidence intervals (CIs) were estimated with adjustment for covariates using Cox regression models. Results We identified a total of 380 eligible patients. The median age was 53 (41, 63) years and 310 (81.6%) patients were male. The main underlying etiologies were dilated cardiomyopathy (51.6%). 204 (53.7%) patients received non-vitamin K antagonist oral anticoagulants (NOACs) while the rest were on warfarin within 3 months. In multivariable analysis, patients with NOACs had a higher likelihood of thrombus resolution than those taking warfarin (HR 1.39, 95% CI 1.08 – 1.79, P = 0.011). Lower LV ejection fraction levels and smaller diameter or thickness of thrombi were also the dominant predictors of thrombus resolution followed by a faster heart rate, a higher white blood cell count, therapy of diuretics, beta-blocker, and parental anticoagulation during hospitalization (eight variables, all P &amp;lt; 0.05). At 3 months, 29 patients (7.6%) suffered major cardiovascular adverse events, including 26 emboli and 3 deaths. One patient (0.3%) experienced an ISTH major bleeding. Conclusions Patients with systemic anticoagulation and positive treatment for heart failure achieved a greater rate of thrombus resolution at 3 months. The option of oral anticoagulation might be favorable NOACs, and further randomized controlled studies are warranted to explore.Forest plot of multivariable analysis.

Clinical outcomes comparison between patients with residual severe and moderate-or-less tricuspid regurgitation after percutaneous edge-to-edge repair: which degree of reduction is significant?

Abstract Introduction Transcatheter tricuspid valve repair (TTVR) for high-grade regurgitation (TR) is an emerging option in inoperable patients, and can improve quality of life. Based on the new 5-grade TR classification(1), all studies have defined procedural success by at least one-grade reduction. While a higher degree of TR reduction should translate into better clinical outcomes, considerable reduction is not always possible. Most often, the regurgitant area is too large for coaptation devices, frequently 2- to 3-fold greater than in mitral regurgitation (MR). Difficult periprocedural guidance, suboptimal acoustic window, shadowing from pacemaker leads, leaflets with multiple scallops contribute to less than perfect results. This study compared long-term clinical outcomes of edge-to-edge TTVR in patients with residual severe TR (STR; III/V) vs moderate-or-less TR (MTR; ≤II/V), despite procedural success. Methods Eligible inoperable patients had chronic symptomatic functional TR despite diuretic therapy. Exclusion criteria were treatable left heart e.g., significant MR, and pulmonary arterial pressure ≥70mmHg, among others. The primary efficacy endpoint was at least one grade TR reduction at 30 days. The secondary endpoints related to long-term improvement in symptoms, quality of life and multiorgan function. Follow-up was carried out between January 2021 and January 2023. Results Forty-three patients, 51% females, had ≥severe (III/V) functional TR, 65% of them massive (IV/V) and 14% torrential (V/V). Mean age was 81.8±4.9 years, with 10.8±6.3% STS-Score. Patients were highly symptomatic e.g., 86% in NYHA stage III-IV, and multimorbid e.g., the majority had advanced kidney and liver disease. The primary efficacy endpoint was recorded in 91% of all patients, with 100% technical success and no device related complications. According to the degree of residual TR we defined 3 subgroups: STR (n=17), MTR (n=22), and no reduction (n=4). Two- or more-grade reduction was present in 91% of MTR and 24% of STR cases(Figure 1). By 12 months, 6 patients died, 2 from each group, 3 of non-cardiac cause. MACE rate was 18.6%. Long-term outcomes in the remaining 15 STR and 20 MTR patients were compared(Figure 2). Improvement in initial NYHA class III/IV occurred in 54% of STR and 77% of MTR patients. KCCQ Score increased by 21.6±17.9 pts. (p&amp;lt;0.001) vs 29.8±15.6 (p&amp;lt;0.001), six-minute walk test by 103.3±65.7 meters (p&amp;lt;0.001) vs 117.5±93.2 (p&amp;lt;0.001). Renal and liver function equally improved in both groups [GFR 51.3±16.5ml/min/1,73m2 to 56.4±21.6 (p=0.043) vs 59.9±17 to 60.1±18.2 (p=0.930); AST 27.4±9.9U/L to 22.2±6.9 (p=0.009) vs 37.5±26.9 to 29.7±10.3 (p=0.112)]. Conclusions Although TTVR should always aim for trace to mild TR, considerable reduction is not always possible. This study indicates that even one-grade TR reduction can significantly impact quality of life, functional capacity and multiorgan involvement, similarly in STR and MTR patients.Figure_1Figure_2